Antenatal / Postnatal Appointment Form

Surname *

First Name *

Address

Street Address *

City *

State *

Country *

Postal code *

Phone Number *

Email *

Date of birth *

Medicare Number, Reference, Expiry *

Eligible for Medicare *

I consent to Sarah Smits claiming Medicare on my behalf for my appointment *

Yes

I consent to paying a travel fee between at time of appointment, $20-$40 depending on distance. *

Yes

You will be contacted to arrange a date and time for your appointment.

Please complete the questions below that are relevant to you so we can best prepare for our time together.

Antenatal

Number of Pregnancies

Number of Births

Estimated Due Date

Gestation

Any current medical or pregnancy related conditions?

Previous Births

Date, type of birth, pregnancy/postpartum complications

Reason for Appointment

Postnatal

Baby Number

Baby's DOB

Type of Birth

Place of Birth

Birth Weight

Type of Feeding

Presenting problem with self or baby / Reason for appointment